Inspection on 10/05/05 for Leys Road (2 to 4)

This inspection was carried out on 10th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Leys Road (2 to 4) 06/09/06

Leys Road (2 to 4) 11/10/05

Leys Road (2 to 4) 22/03/05

Leys Road (2 to 4) 05/05/04

Leys Road (2 to 4) 04/03/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Leys Road (2/4) 2/4 Leys Road Hemel Hempstead Herts HP3 9LX Lead Inspector Alison Jessop Unannounced 10 May 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Leys Road (2/4) I52 s19447 Leys Road v224847 100505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Leys Road Address 2/4 Leys Road, Hemel Hempstead, Herts, HP3 9LX Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01442 389 214 01442 389 214 Hightown Praetorian & Churches Hosuing Association Mr Ian Searle CRH Care Home 7 Category(ies) of MD-7 registration, with number of places Leys Road (2/4) I52 s19447 Leys Road v224847 100505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5 May 2004 Brief Description of the Service: Leys Road provides accommodation, care and support for seven service users who have a history of mental health issues. The home is arranged on three floors. There is no lift so the home would be unsuitable for anyone with restricted mobility. The service users are currently all able to manage the stairs independently. Accommodation comprises of a quiet room, kitchen, lounge, dining room and toilet on the ground floor. The first floor consists of three bedrooms, shower room, toilet and office. The second floor comprises of four bedrooms, two bathrooms and a toilet. Leys Road is situated close to the town centre of Hemel Hempstead. Leys Road (2/4) I52 s19447 Leys Road v224847 100505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over half a day and was the first of the new inspection year. Most of the time was spent gaining feedback from service users and staff. All feedback gained was very positive. What the service does well: What has improved since the last inspection? What they could do better: Some individual risk assessments were required in relation to the environment. The homes complaints procedure needs to be reviewed. Leys Road (2/4) I52 s19447 Leys Road v224847 100505 Stage 4.doc Version 1.30 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Leys Road (2/4) I52 s19447 Leys Road v224847 100505 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Leys Road (2/4) I52 s19447 Leys Road v224847 100505 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 The homes assessment and admission procedures are robust ensuring that service users needs can be met on admission to the home. EVIDENCE: The home operates a robust referral procedure. Along with a completed application form, the home requires a medical reference from a GP and copies of any CPA Risk Assessments. Additionally the manager or representative for the home completes an assessment to ensure that the placement will benefit the service user and that their needs can be met at Leys Road Leys Road (2/4) I52 s19447 Leys Road v224847 100505 Stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7 Care Plans observed were of a high standard offering a good picture of the service user’s needs and how these needs were to be met. EVIDENCE: A lot of information had been included in the care plans observed and comprehensive Risk Assessments had also been completed. All documentation had been reviewed regularly and were signed and dated by service users. Service users spoken to confirmed that their views and rights are respected. This was included in service users care plans and risk assessments. Leys Road (2/4) I52 s19447 Leys Road v224847 100505 Stage 4.doc Version 1.30 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,13,15,16 & 17. Service users are encouraged to maintain independence both within and outside the home. Individual arrangements had been made for them to fill their time with appropriate activities and tasks, ensuring that they maintain their sense of purpose and identity. EVIDENCE: A house rota where cooking, cleaning and other tasks are shared is devised with service users on a weekly basis. One service was on his way to his voluntary job on the morning of the inspection. Others went to town or to the local shops, or stayed at home to complete chores. One older service user spoken to said that she prefers to stay in and watch television. Once a month music and movement is held at Leys Road, the feedback about this was very positive. Relatives and friends are welcome in the home provided that this does not inconvenience others. There is a pay phone in the home, which can be used by Leys Road (2/4) I52 s19447 Leys Road v224847 100505 Stage 4.doc Version 1.30 Page 11 service users, however it was stated that there is little privacy. One service user stated that she would like to get a phone line in her bedroom. A service user confirmed that she voted in the recent General Election along with others living at Leys Road. The menu is planned with service users on a weekly basis and a cooking rota is drawn up. Lunch is usually a snack, service users choose what they would like to eat and those that can prepare their food individually. One service user assists staff to shop for the house food. Leys Road (2/4) I52 s19447 Leys Road v224847 100505 Stage 4.doc Version 1.30 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19, 20,21 Support is offered to service users in a discreet and sensitive manner, thus maintaining their dignity. Staff encourage service users to attend to their own needs ensuring that service users maintain their independence. EVIDENCE: Support offered was very individualised and service users were encouraged to be as independent as possible. Leys Road is not suitable for people with restricted mobility as all bedrooms are on upper floors with no alternative access. Community health is accessed as required. Staff support is provided if required and records are maintained of all appointments or visits to/from healthcare professional. The medication was generally well stored and good records were maintained. Service users care plans included a statement on their dying wishes, which has been signed by the service user. Leys Road (2/4) I52 s19447 Leys Road v224847 100505 Stage 4.doc Version 1.30 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 &23 House meetings are held regularly and service users are able to view their opinions, concerns and ideas. EVIDENCE: Service users confirmed that they would know how to make a complaint should this be required. A copy of the complaints procedure is clearly displayed on the notice board in the entrance to the home. Although there is a Complaints Procedure this does not detail the timescales in which complaints are dealt with, the Complaints Procedure must also include the contact details for the Commission for Social Care Inspection. A grumbles book is maintained in the lounge but has not been used for many years. Copies of the Hertfordshire Protection of Vulnerable Adults Procedure were available in the office. Staff confirmed that they had received training on adult abuse. Staff records were unavailable for inspection due to the managers absence that day. All staff spoken to confirmed that they have been provided with a copy of the GSCC Code of Practice. An original copy of a service users birth certificate was found on their file in the office. A requirement has been made for this to be stored more securely away from the day to day access of staff, this is to protect service users from any forms of financial abuse. Leys Road (2/4) I52 s19447 Leys Road v224847 100505 Stage 4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25 & 30, Leys Road is bright and airy and attractively decorated offering a comfortable homely environment to its service users. EVIDENCE: The home is in keeping with the local community. It is well maintained and attractively decorated. Furnishings and fittings are domestic in style and meet the service users needs. On the day of the inspection the home was seen to be clean and tidy and was free from odour. Some service users who had gone out or were in communal areas had locked their bedrooms, whilst others chose not to. All service users spoken to confirmed that they had been offered a key to their rooms. Leys Road (2/4) I52 s19447 Leys Road v224847 100505 Stage 4.doc Version 1.30 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 & 36 Staff undertake lengthy discussions of individual policies or procedures during team meetings to ensure that they are kept up dated. The well trained and well supported staff group provide a good standard of care for the service users. EVIDENCE: Staff spoken to stated that they receive regular mandatory and role specific training. One new member of staff gave access to their induction portfolio which was very comprehensive and covered all aspects. Staff confirmed that they receive regular individual and group supervision. They also receive an annual appraisal. One new member of staff stated ‘I can get advice from my manager if I’m not sure about something, even when they are not on duty I can use the on call system’. Leys Road (2/4) I52 s19447 Leys Road v224847 100505 Stage 4.doc Version 1.30 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 Whilst it was necessary to make two requirements; overall, the safety and welfare of service users is maintained appropriately. EVIDENCE: All records in relation to gas, fire, water and electrics are maintained ensuring that any issues can be identified and rectified maintaining a safe environment. One service users bedroom was cluttered with various personal items and consumables. A risk assessment is required in relation to this and all risks minimised. Water temperatures recorded in the bathroom and shower rooms have exceeded recommended levels and although notices had been displayed on the bathroom doors, a risk assessment is required specifically in relation to this. The manager must ensure that adequate precautions are in place to ensure the safety of the service users and staff. Leys Road (2/4) I52 s19447 Leys Road v224847 100505 Stage 4.doc Version 1.30 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x x x x 3 Standard No 11 12 13 14 15 16 17 3 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x x x x 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Leys Road (2/4) Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x I52 s19447 Leys Road v224847 100505 Stage 4.doc Version 1.30 Page 18 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 22.1 Regulation 22 (4) & 22 (7) (a) & (b) 16 13 (4) (a) (c) 13 (4) (a) (c) Requirement The complaints procedure must include timescales in which action must be taken. It must also refelect the details of the Commission for Social Care Inspection. Service users original identification documents must be stored safely. Risk assessments must be carried out on hot water levels and risks minimised. A risk assessment must be carried out in cluttered bedroom and risks minimised. Timescale for action By 24.6.05 2. 3. 4. 23.6) 42.6 42.6 By 27.5.05 By 27.5.05 By 27.5.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 16 Good Practice Recommendations Service users should be given the opportunity to explore the possibility of installing a personal phone in their bedroom. Leys Road (2/4) I52 s19447 Leys Road v224847 100505 Stage 4.doc Version 1.30 Page 19 Commission for Social Care Inspection Mercury House 1 Broadwater Road Welwyn Garden City Herts, AL7 3BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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